Autism and the Gut

Brannon Alberty, MD Medical Director of Pediatric Gastroenterology Our Lady of the Lake Children’s Hospital October 11, 2013 Objectives

• Common GI problems associated with autism • Common treatments for these problems • So what’s the deal with the whole leaky gut thing? Ground Rules

• Not here to start any fights or insult anyone • Save Questions/Comments for the end • Levels of evidence • Every patient is unique • Let’s raise the level of conversation from theory/emotion, to what we know Common GI Problems

• Constipation/encopresis 33% vs 17% • Oral aversion 25% vs 16% • No difference in rate of abdominal pain,

reflux, or diarrhea Pediatrics. 2009 Aug;124(2):680-6

• Obesity 20% vs 13%Child Obes. 2013 Apr;9(2):125-31 • Reflux symptoms are different Constipation/Encopresis

• Functional – Diet – Toilet habits – Sedentary – Bacteria – Genes – Mild anatomic issues • Organic – Medicines – Thyroid – Celiac Constipation

• Diet – limit milk, peanut butter, carbs; more fiber (soluble vs insoluble) • Toilet habits – after every meal, 1 minute/yr • Probiotics – Align, lactobacillus, yogurt

• Osmotics – Miralax Z Gastroenterol. 2006 Feb;44(2):167-72., milk of magnesia • Stimulants – senna, bisacodyl • Weekend cleanouts GERD

• Everybody refluxes • Disease is with pain, respiratory, feeding • High pain threshold and limited verbal • Present with feeding refusal or self-mutilation • Diagnosed with history, endoscopy, or pH probe…UGI not so much GERD Treatments

• Low acid diet • Elevating head of bed • Acid suppression – Zantac, Nexium, Prilosec, Prevacid • Nissen Fundoplication Feeding Refusal

• Organic – Esophagitis (endoscopy) – Dysphagia (pharyngogram) – Constipation (cleanout) – Oral/dental (exam) – Gastric (endoscopy) • Psychogenic – formula overfeeding (wean formula) – Oral aversion (feeding therapy) Feeding Refusal Treatment

• First look for underlying cause – If the child has esophagitis then you are wasting your time. • If not constipation, esophagitis, dysphagia • If not over feeding with formulas • Then feeding therapy Obesity

• About 20% of ASD kids 13% for other kids • Problems : ortho, DM2, fatty liver • Weight = (calories in–calories out) • Unknown factors include genes, intestinal flora • Calories in = carbs and portion size and snacks • Calories out = TV, ipad, absorption, metabolism, exercise • Autistic kids spend 2x as much time on TV and

video games as their siblings. J Autism Dev Disord. 2013 Jun;43(6):1258-71 Obesity Treatment

• Cut the calories in – limit carbs, portion sizes • Increase calories out – cut screen time to 1hr • Weigh every month • Whole family • Outside “Autistic Enterocolitis”

Pioneer medicine or quackery? Proposed by Andrew Wakefield and Arthur Krigsman The study included only 12 children Lymphonodular hyperplasia –we see this in most kids Ileitis or colitis – the biopsies results were later falsified Measles in the tissue – not reproduced 3 never had autism, 5 had developmental problems before the MMR Wakefield was personally paid $600K by the plaintiffs lawyers and applied for a single vaccine patent before releasing the paper “Leaky Gut”

• Long on theory, short on evidence. • One paper showed 36% of autistic kids had a positive IPT, 21% of family members, and 5%of controls J Pediatr Gastroenterol Nutr. 2010 Oct;51(4):418-24 • Association? Interesting. Cause/effect is unknown. Theories abound about LPS, casein, gluten, etc. • Interventions need to be harmless for now • Leaky gut is not unique to ASD • Most ASD kids DO NOT have a leaky gut Diets Demystified

• Coincidence, Association, Causation • Gluten-free – Celiac, wheat allergy, constipation, gluten intolerance • Casein-free – Milk allergy, constipation, lactose intolerance • Beware Over-restriction Questions?